<!DOCTYPE html>
<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"/>
        <title>Web Form</title>
    </head>

    <body>
        <div class="container c26 tpm">
            <h2 class="bottom">Student Profile</h2>
            <hr />
            <form id="frmStudent" method="post">
                <div class="flashmsg"></div>
                <div class="c26">
                    <div class="container pad">
                        <div class="column c12">
                            <label class="left">First Name:<br /><input class="textbox" id="txtFName" name="txtFName" type="text" size="30"  /></label><br />
                            <label class="left">Last Name:<br /><input class="textbox" id="txtLName" name="txtLName" type="text" size="30"  /></label><br />
                            <label class="left">Street:<br /><input class="textbox" id="txtStreet" name="txtStreet" type="text" size="30"  /></label><br />
                            <label class="left">City:<br /><input class="textbox" id="txtCity" name="txtCity" type="text" size="30"  /></label><br />
                            <div class="tpb tpm">
                                <strong>Color: </strong><br />
                                <label><input name="optColor" type="radio" value="red" /> Red</label>&nbsp;
                                <label><input name="optColor" type="radio" value="green" /> Green</label>&nbsp;
                                <label><input name="optColor" type="radio" value="blue" /> Blue</label>&nbsp;
                            </div>
                        </div>
                        <div class="column c12">
                            <label>State:<br />
                                <select name="lstCountry" class="c11">
                                    <option value="br">Brazil</option>
                                    <option value="ca">Canada</option>
                                    <option value="fr">France</option>
                                    <option value="ja">Jamaica</option>
                                    <option value="usa">United States</option>
                                    <option value="uk">United Kingdom</option>
                                </select></label><br />
                            <label>State:<br /><input class="textbox" id="txtState" name="txtState" type="text" size="30"  /></label><br />
                            <label>Zip:<br /><input class="textbox" id="txtZip" name="txtZip" type="text" size="30"  /></label>

                            <div class="tpb tpm">
                                <strong>Contact Via: </strong><br />
                                <label><input name="chkFeatures" type="checkbox" value="phone" /> Phone</label>&nbsp;
                                <label><input name="chkFeatures1" type="checkbox" value="email" /> Email</label>&nbsp;
                                <label><input name="chkFeatures2" type="checkbox" value="fax" /> Fax</label>&nbsp;
                            </div>
                            <div class="tpb tpm">
                                <strong>Model: </strong><br />
                                <label><input name="chkModel[]" type="checkbox" value="0" /> Mb 109</label>&nbsp;
                                <label><input name="chkModel[]" type="checkbox" value="1" /> TV 1292</label>&nbsp;
                                <label><input name="chkModel[]" type="checkbox" value="2" /> FT 4342</label>&nbsp;
                            </div>
                        </div>
                    </div>

                    <div class="rax-inactive-pal hlf-pad" align="right">
                        <div class="left">The form will retain its values after being submitted.</div>
                        <input id="btnSave" type="submit" value="Submit" />
                    </div>
                </div>

            </form>

        </div>

    </body>

</html>
